Smallpox Vaccine Guidelines Readied

NHNE News List Current Members: 690 Subscribe/unsubscribe/archive info at the bottom of this message. ... EDITOR S COMMENT: If there is an outbreak of

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, Sep 23, 2002

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Current Members: 690
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EDITOR'S COMMENT:

If there is an outbreak of smallpox, and if the policy outlined in the story
below is set in motion, then it will be important for all of us to be as
informed as possible. I have, therefore, included a list of links along with
this article to balance the often panicky and poorly researched smallpox
policies trumpeted in the mainstream press. In particular, I would encourage
all of you to read this post:

Federal health officials will issue detailed guidelines today for
vaccinating the entire U.S. population against smallpox within five days of
an outbreak of the dreaded disease.

Intended as a blueprint for state and local health officials nationwide, the
unprecedented move reveals a growing belief within the Bush administration
that even one case of smallpox anywhere in the Western Hemisphere would
signify a terrorist assault and should therefore trigger a far more massive
response than officials had previously suggested, said two experts involved
in the planning.

The manual being sent to health commissioners in the 50 states and the
District of Columbia offers advice on how to operate mass vaccination
clinics -- from logistical issues such as parking to the medical challenge
of treating severe side effects. It offers suggestions on utilizing the
National Guard, recruiting translators, building intricate data systems and
contending with extreme weather conditions.

For now, the Bush administration does not anticipate inoculating the
nation's 288 million residents -- partly because the threat of an attack is
unknown and partly because the vaccine can cause severe, sometimes fatal,
side effects. The vaccination plan would be activated only if an outbreak of
the deadly disease occurred, an event administration officials characterize
as unlikely but not impossible.

"This is a very detailed, thoughtful recipe for response" to a bioterror
incident, said Michael Osterholm, a public health expert at the University
of Minnesota who is advising the federal government. Using the template,
states and cities should be able to devise plans "for vaccinating the
largest amount of people in the shortest time possible," he said.

Smallpox has not been seen in the United States for decades, and the disease
was declared eradicated worldwide in 1980. Still, it is perhaps the most
feared biological weapon because it is contagious, often incurable and can
kill at least one-third of its victims. Since routine vaccination was halted
in this country in 1971, there is little immunity left in the population and
little expertise in dealing with the disease or vaccine.

Only the United States and Russia are known to possess stocks of the virus,
but security experts fear a hostile nation such as Iraq may have acquired a
cache of the virus. Vice President Cheney has contended the risk of attack
may necessitate inoculating every American as a protective measure.

"One of the real concerns about Saddam Hussein, as well, is his biological
weapons capability," he said recently on NBC's "Meet the Press." "The fact
that he may, at some point, try to use smallpox, anthrax, plague, some other
kind of biological agent against other nations, possibly including even the
United States."

Ten months ago, Health and Human Services Secretary Tommy G. Thompson signed
a $428 million contract to buy a dose of vaccine for every American.
Production is under way, and the United States already has stockpiled nearly
100 million doses.

Federal experts since have been working furiously on two tracks: a
vaccination program for the emergency medical workers most likely to see an
initial case of smallpox, and a mass vaccination plan if an attack occurs,
said Julie L. Gerberding, director of the federal Centers for Disease
Control and Prevention.

"We have to be able to do both," she said in a recent interview.

Pre-vaccination, as it is known in public health, would be targeted to
medical personnel, who could respond to an attack knowing they are
protected. Plans are underway to begin vaccinating tens of thousands of
"first responders," perhaps by the end of this year.

There have been no plans to make the vaccine available to the public in the
absence of any cases. But officials have been debating what would be the
best response to an outbreak. Last winter, the CDC released a blueprint for
containing a smallpox outbreak based on the "ring vaccination" strategy used
during the campaign to eradicate the disease. Ring vaccination involves
starting with the people closest to an exposure and working out in
concentric circles.

There is growing recognition, however, that although that approach worked
well for a naturally occurring outbreak during a time when air travel was
rare, it would be no match for a terrorist with the ability to release the
virus in several locations simultaneously, said Jerome M. Hauer, acting
assistant secretary for HHS's Public Health Emergency Preparedness.

"You begin with ring vaccination, but in a big outbreak obviously mass
vaccination would be part of the plan," he said. Federal officials are
requiring states to develop plans for vaccination within five days, he said,
because it is widely believed that even if a person has been exposed to the
virus, a vaccine given in that time frame will provide immunity.

Administration officials refused to release the manual until state health
commissioners receive it. But in interviews with The Washington Post,
several described the scenario for responding to a smallpox attack.

At the first hint of a smallpox case, the CDC in Atlanta would begin
dispatching emergency teams to the area to confirm the outbreak and begin
vaccination.

Yet the suspicion that terrorists would strike more than one location "would
require us to be in many, many places simultaneously," one federal planner
said. "That would completely deplete our assets."

Instead of sending its staff to every corner of the country, the CDC plans
to ship the vaccine and let states handle inoculation, Osterholm said. The
National Pharmaceutical Stockpile, he said, "can be at any hamlet in this
country in 12 hours." Officials have not said how much it would cost or how
it would be paid for.

HHS has received assurance that even if air traffic were halted, as it was
immediately after the Sept. 11 attacks, planes transporting vaccine would
have clearance. Vaccine would be delivered in waves much the way a grocery
store receives its weekly shipment of milk in batches.

The manual, which is almost 100 pages, was developed in consultation with
local health officers, medical societies, the military and businesses such
as UPS and Federal Express that have logistical expertise, said an adviser
to Thompson. Much of its contents were based on previous large-scale
vaccination programs, such as the 1995 meningitis outbreak in Mankato,
Minn., in which 26,000 people were inoculated in four days.

Each state must determine where vaccination clinics would be located, who
would staff them, how to counsel people on the potential risks of
vaccination and most importantly, how to move hundreds of thousands of
people through the process calmly and quickly. Some communities might select
large shopping malls or sports arenas because of parking availability;
metropolitan centers might rely on buses and subways to bring people to
clinics.

Every state will need provisions for everything from inclement weather to
the person who faints at the sight of a needle, Osterholm said. "Are you
going to have a line stretching 21/2 blocks in the snow or blistering heat?"
he said, describing one challenge.

The guidelines urge states to address the need for bathrooms,
transportation, a media strategy and a medical questionnaire, as well as how
to separate and treat any potential smallpox cases. They also include sample
consent forms if states must administer an unlicensed vaccine. Two
administration sources said they hope the vaccine soon will be re-licensed.

Although bioterrorism is a new challenge, large vaccination campaigns are
not, Osterholm said. "The public health system delivers vaccine to our
nation's children every day, overcoming language, transportation and
financial hurdles," he noted.

Aside from an assumption that some health care workers will be vaccinated
before an attack, the document does not resolve enormous questions
surrounding that issue.

Last month, Thompson sent recommendations to the White House on how many
people should be inoculated in advance. Although a CDC advisory panel has
recommended vaccinating about 20,000 medical personnel, several
administration sources said President Bush is weighing a proposal on the
order of 500,000 people.

"Until a decision is made on pre-vaccination," Hauer said, "our efforts
continue to focus on bioterrorism detection and response."